Sunday, April 30, 2006

Now that's an interesting job... to be the doctor at Google Headquarters in Mountain View. Dr. Razavi is a physician working part-time for Google, answering questions in her blog about ticks, whooping cough, coccygodynia, among other things. She appears to also have a private practice on the side (or is the Google job on the side?).

At one point in my life, when I had a handful of "side jobs"; one of them was to run a chat room in AOL's Depression Forum on Sunday nights, answering general questions about depression and its treatment. I started doing it for a friend gratis, and it eventually turned into a paid job for a couple years. Until the internet bubble burst, and all these start-ups went belly-up. What I provided was education and information. No therapy. No treatment. No advice (other than to say to "ask your doctor").

My malpractice insurer asked all the insureds about their internet activities. I dutifully explained what I did. They asked for a transcript of a chat, which I provided. They then told me that, not only would I not be covered for this activity (which I wouldn't expect) but that if I did not stop doing it, they would drop me, as they could not quantify the risk exposure. I recall being incensed that providing needed education about what the symptoms of depression were, or what common side effects of Prozac were, was not being embraced but strongly discouraged. (No wonder our health care system is imploding.)

My building righteous rage to fight "the man" on this one was quickly snuffed when AOL ended the contract with my friend's company, thus ending the service. My drive to share information has not been quenched, however. I later ran an e-newsletter about psychiatric medications for a couple years, stopping because the squeeze wasn't worth the juice (it took up too much time).

So I understand Dinah's blogging apprehension. Writers and educators (even physicians, for the most part) have a desire to share their thoughts, ideas, and knowledge with those who are interested. So, the rabbit hole gets deeper. Yet, the number of blogging and sharing netizens in the World Wide Wonderland continues to grow.

I can't help but wonder where it will all lead. Hopefully, we'll all get there before... someone yells, "Off with their heads!"

At a time when people are increasingly concerned about the criminalization of the mentally ill, when 1 in 10 prisoners in the United States are being treated with psychotropic medications, we have now come full circle. If jails and prisons are the new psychiatric hospitals, then psychiatric hospitals are becoming the new prisons. Presently thousands of sex offenders are committed to state psychiatric facilities under sexual predator acts. The state of New York is proposing a $130 million budget specifically to build a psychiatric facility for sex offender confinement. Minnesota's confined sex offender population has doubled in the past five years, and the current proposed budget includes $50 million dollars for additional facilities and security enhancements to the forensic hospital there.

Meanwhile, patient advocacy organizations promote outpatient commitment and community treatment while state hospitals are being closed due to budget cuts. It looks like the only way the public mental health system can stay in business is to treat criminals.

Chuck Klosterman, in One Slice With Extra Meaning, talks about how he accidently dumped an entire canister of red pepper onto his pizza slice. "...I suppose I just could have ordered another slice.... Instead, I acted as if I had done this on purpose." In front of the other pizzaria patrons, he painfully injests the peppered pizza and goes on to say, "Very often, I don't know why I do the things that I do: it is my assumption that many people feel this way pretty much all the time. But whenever you do something especially idiotic, and if your reaction to such an event is especially unreasonable, you're forced to question (a) the motivations that drive your behavior and (b) whether such motives even make sense."

Klosterman could be a patient: How many times have we asked patients why they've done something seeming nonsensical to have them reply "I don't know?" And how many times have we asked the same question of ourselves, only the come up with the exact same answer? ---Hmmmm, and I've started a blog because.....

Mark Edumundson, in Freud and the Fundamentalist Urge talks about Freud and Hitler and Freud's theories on how tyrants come to power: "Take a drink (or two), take a lover, and suddenly the internal conflict in the psyche calms down. A divided being becomes a whole, united and (temporarily) happier one. "Freud had no compunction in calling the relationship that crowds forge with an absolute leader an erotic one."

And, finally, in A Question of Resilience, Emily Bazelon asks if genetics, and specifically the long allele of the 5-HTTT gene, play a role in contributing to the question of why some people-- and some Rhesus Monkeys-- are more resilient than others in the aftermath of abuse.

Friday, April 28, 2006

Yesterday, there were no blog entries because I spent most of the day on a train, traveling to and from the funeral for a member of my extended family. His death was tragic and completely unexpected—a healthy man who should have lived for decades more, he died at work from a cerebral hemorrhage.

A few weeks ago, I also lost a patient to a chronic and incapacitating illness. The death was horrible, culminating in pain and cachexia, but it was not unexpected, and perhaps there was, at least for the patient, some sense that death would yield relief.

At any rate, death has been on my mind lately.

So, we try to live life right: there is a list. The list is fairly long, though I think I can summarize at least some of it. Low fat (or, this week, low trans fat), diet, regular exercise, lots of calcium (oops, that may have been last week), no smoking, drink only in moderation—and, please, red wine. Seat belts. No illicit drugs; caffeine (sorry, Clinkshrink), and aspartame are a little lower down on the list but still there. Smoke detectors, definitely, and remember to check the batteries once a month. Multivitamin and baby aspirin, perhaps. Sunblock. And finally there’s the medical screenings: mammogram, Pap smear, PSA, colonoscopy, to name just a few. Hormone replacement therapy is out, fish oil supplements are in. I’m sure you can add to the list.

We grow up listening to directives on how we should live as determined by the medical community, or perhaps by the medical community in concert with the pharmaceutical industry and unclear political agendas. The Food Pyramid, as taught to all our children and described on the back of every cereal box, was never a scientifically-determined recipe for good health, it was voted on by a committee, and it sure sounded good.

The pretext of how to live life right is that if you follow the directives, you get to live a long, healthy, and fruitful (pun intended) life-- if all that exercise doesn’t destroy your joints, that is. The subtexts, however, are ones of guilt, fear, and social ostracism. We live in a society that praises “taking care of yourself,” where foregoing hedonist pursuits and rigid self-discipline are something to aspire to. Of course our neighbor had a heart attack, didn’t you see him chowing down that chocolate éclair the other day? Do you know how many grams of fat are in that thing? And if you aren’t on a low-fat, high-fiber diet, exercising a minimum of four hours a week, then perhaps you deserve to have that recurrence of your breast cancer. We fool ourselves into thinking other people get what they deserve and if only we do it all exactly right, we won’t die. While, as a physician, I won’t encourage anyone to smoke or drive after drinking-- or even to skip the next dose of lipitor-- the truth, I believe, is that we live until we die and we have much less control then we think.

People have many anxieties, as a psychiatrist I get to hear them. Terrorists, bird flu, violent criminals, shark attacks, plane crashes-- we all have things we worry about, many of them are things beyond our control.

I am worried that I will miss a hot fudge sundae. I carry this fear that I will do it all right, follow all the rules, say No to yet another hot fudge sundae—all in the name of healthy living and the pursuit of longevity-- and what if, in the end it doesn’t matter?

Wednesday, April 26, 2006

Clinkshrink warns of the dangers of caffeine intoxication, a DSM-validified diagnosis, which we may or may not try to use in our insanity defense pleas and our quest for equal access. The issue of determining where normal behavior (--hmmm, that cup of coffee I just injected was okay, right?) bleeds into symptomatology is the psychiatrist's challenge.

Nice to see that the Supreme Court reviewed Eric Clark's case. He's the Texas kid who developed schizophrenia and killed a police officer, thinking the officer was an alien. Unfortunately, the Washington Post reports that the Court will probably interpret the case very narrowly, thus not affecting many of the states that have reduced or eliminated the ability to use insanity as a mitigating factor in criminal trials. (So, maybe they'll render an opinion that all citizens have the right to sanity, and require true access to mental health treatment for all US citizens? I must be delusional.)

Hmm, I note that CCHR (Citizen's Commission on Hubbard... no, Human... Rights) testified at the hearing (CCHR is a Scientology-driven organization). Now that's Supreme Irony: an organization founded on the belief that aliens are among us testifying that Mr. Clark's defense (that he thought the police officer was an alien) does not justify an insanity plea... in fact, that there is no such thing as insanity. At least they are internally consistent. (but don't they have a conflict of interest?)

Tuesday, April 25, 2006

The DSM criteria for caffeine intoxication includes restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility and psychomotor agitation. Regardless, the web site for one of the best coffee shops in Charm City has registered over 2.8 million hits in the past two years---that's nearly 4,000 web visitors every day. Why such a demand for such a noxious substance?

Well, duh. There is little question remaining about the addictive nature of caffeine. What remains to be addressed are the implications of caffeine addiction, or caffeinism, on legal or social policy if there is general acceptance that caffeine addiction or dependence is a mental disorder. The DSM is careful to couch it's diagnostic criteria in the following disclaimer:

The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency.

Another way of putting this would be: 'just because a diagnosis is in this book doesn't mean you can use it in your lawsuit.' This disclaimer doesn't prevent people from trying, however. Remember the Twinkie Defense? I foresee caffeine withdrawal used someday as a mitigating circumstance for a criminal offense, or perhaps as the basis for an ADA 'reasonable accomodation' claim. Hmm...perhaps my office should always be within walking distance of Starbucks. That's reasonable, right?

When I told a told a friend (ah, Clinkshrink) I was going to start a blog, she said,"Your patients will read it!" Is this a problem? My first thought was: I have a novel out there that opens with a mental health professional stumbling upon her cross-dressed husband, how much worse can it get? True, most of my patients haven't stumbled upon my novel, and so far, none of those who've read it have fired me. It's a funny issue though, being a psychiatrist, trying to maintain some neutrality for the patients-- I'm not a psychoanalyst, but I do keep things fairly neutral both because I think my personal affairs would be a distraction in therapy, and because I want my privacy. There are no pictures of my family displayed, and so far the most self-revealing thing I've done is to put a Red Sox cap on the table in my waiting room the morning after they won the World Series.

On the other hand, being a writer is a somewhat public event, at least in brief spurts. Google has changed everything, and some of it beyond my control. I've googled me (as have some of my patients) and I'm in a bunch of places, including tied to a faith-based site called Psycho-babble run by Dr. Bob--- It's not me, but another EM, there are a few of us out there. I'm trying to figure out how to be the EM's who's listed in Who's Who in London. So, I guess my patients can unearth what they want, and I will admit to the Red Sox fan stuff, even the novel with a transvestite, and the Op-Ed rant about Malpractice Reform. Still not certain what I'll write about here, I don't plan to talk about my patients in a disrespectful, disparaging, or revealing way.

Finally, I'm left with the question of Is This Wise? for vague reasons...perhaps even Is This Safe? Other doctors seem to vary with how identifiable they are on the Web, and I haven't found another psychiatrist blog that isn't anonymous. Maybe there's a reason, maybe I'm missing something here, and should mask my identity. Tell me what you think...

Sunday, April 23, 2006

[Posted by ClinkShrink]
In the course of reviewing for my forensic recertification exam I am struck by the dramatic and divergent changes in patient privacy issues since I did my fellowship ten years ago. When I was in training the standard assumption was that psychiatric records were private and that a written release was required from the patient to disclose any information. That was pretty simple. We didn't have to think about electronic medical records, email, faxes, telepsychiatry or many other forms of electronic communication either because they just didn't exist or weren't in common use. Then came HIPAA. Enough said.

The latest and most counter-intuitive twist in patient privacy is now the U.S. Patriot Act. What this means for psychiatrists is that if the government wants your records, you give it to them. Period. And you can't tell your patient. Ever. A request for records under the U.S. Patriot Act comes in the form of a National Security Letter (NSL). According to the Foreign Intelligence Surveillance Act (FISA), an NSL must be approved by a judge of the Foreign Intelligence Surveillance Court. However, there is no requirement for any standard of proof that a national security issue is at risk---no "reasonable suspicion", no "probable cause"---and no mechanism to challenge the letter or appeal the granting of the NSL.

If you receive a National Security Letter you may not tell your patient that you received it or that you have turned their psychiatric records over to government investigators. This gag order is permanent. And the request is not limited to any particular physical location---keep this in mind if you have a home office.

As you struggle every day to interpret and comply with HIPAA regulations, it's ironic to know that the government could suddenly decide to rifle through your home office filing cabinet and there's really nothing you can do about it.

For those of you interested in learning more about the ramifications of NSL's and the Patriot Act on your practice, download the ACLU's pdf file on this issue:

Saturday, April 22, 2006

[Guest blogger here, Roy]: I don't know how many of you watch Keith "keep your knees loose" Olbermann's Countdown on MSNBC, but he tends to deliver news with an edge. For example, every night he has a segment titled, "Worst Person in the World." I think a recent one was about Phillip Winikoff, a 76yo man in a white lab coat going door-to-door saying that he was from the health department providing free, in-home screening breast exams. What a boob! [sorry--I can't resist a bad pun]

Keith Olbermann has recently focussed his lens on Tom Cruise. Before Mr. Cruise and Katie Holmes had their baby, Suri, this week, Keith was pondering whether he required Katie to have a "silent birth", as prescribed by his, umm, religion. My understanding is that the newborn must experience extreme quiet -- no touching, no noise -- for some period of time, I guess to let it chill out... you know, provide a little stress innoculation to protect it from future psychopathology, lest it be taken advantage of by unscrupulous psychiatric quacks who would push mind-altering drugs on to the would-be maladjusted, unsuspecting, little alien Thetan channeler, rather than the much more appropriate method of clearing one's bad karma by being audited by a specially trained, well, auditor, who uses some high-tech E-meter device to slowly but surely remove each and every last of the two-thousand-some galactic Thetan spirits which inhabit each of us when we are born. ::taking a deep breath::

Where am I going with this? Oh, yeah. Keith Olbermann pointed out that little Suri just happens to have been born on the same date that Brooke Shield's baby was born. You may recall that Mr. Cruise ridiculed Ms. Shields for seeking treatment for her postpartum depression, rather than handling it his way. Mr. Olbermann wondered what will happen if Ms. Shields also develops a postpartum depression (up to 10% of women develop postpartum depression after giving birth). We can guess she won't take medication or see a psychiatrist. I figure Tom will treat her. After all, he knows Psychiatry. Then, "Doctor" Phillip Winikoff can provide him a free examination.

[Posted by ClinkShrink]I suppose I could rant---quite easily now, as a matter of fact---about the cost of re-certification exams. I mean really, what are they spending a $2100 registration fee on? It's a computer test, for heavens sake. No one even needs to score it. I know what programmers get paid so I can tell you that money ain't going to the techies who built the thing. If the project was outsourced to India they could have hired over 200 computer programmers for the cost of one physician's registration fee. I suppose I could be comforted by the fact that I'm supporting 200 Indian families, but somehow that just doesn't cut it right now when I'm mainly concentrating on not failing the test.

I was stretched out on the couch, watching television with my family, but my attention had wandered.“Are bras electric?” Bethlet, my eleven-year-old, asked. Huh?“Are bras electric?” She repeated the question, and this time I convinced myself I’d heard it right. I didn’t get it.“There was a commercial for a bra,” Bethlet explained, “ and they said it was wireless. If it’s wireless, doesn’t it have to be electric?”I had to think about this to figure it out, but when I was done laughing, I was left to ineptly explain the concept of underwire support. I struggled for the right image of the electric bra: a small battery concealed in a pocket next to the hooks, or perhaps a powerpack making the entire undergarment rechargable. There my imaginary electric bra sat, next to our laptops, cell phones, palm pilot, and blackberry, getting revved up for the day.I keep thinking this anecdote must have some relevance to psychiatry, it just has to....

In November, I spent two weeks working in Louisiana as part of SAMHSA's Katrina Assistance Project. I wrote about my experiences in an essay I will link to here:http://shrinkrap2.blogspot.com/" >Reflections of a Katrina Psychiatrist

Friday, April 21, 2006

This is Blog for psychiatrists to talk about issues pertaining to the practice of psychiatry. Somewhere to talk about ideas, controversies, clinical issues, whatever pushes your buttons.

It's fine to vent here, but if you're talking about a patient issue, please disguise the patient's identity completely, and if you're talking about a patient with unique symptoms, change those as well-- keep the flavor of the problem, but don't risk breaching confidentiality.

What this isn't: a resource for patients, though I will include some links to other mental health sites. This is a resource for docs.

I'm still trying to find a voice for this; it's my first blog and I'm not sure what I can do with it, so bear with me while I work on getting the kinks out!

Our hypothetical patient enters the office; he's never seen a psychiatrist, and he's here because he is overwhelmed with sadness after being laid off from work. He isn't sleeping well, he's lost ten pounds, he's having trouble organizing his job search, he's irritable and arguing with his wife. He is clearly a bright guy, but tells us he's lost jobs before and feels he isn't living up to his potential. He's not psychotic, he's not dangerous. A full evaluation is done and some decisions are made about what type of treatment to begin.

So here's my question: When do we have him return for the next visit?

Is that a silly question? And do I really want an answer? You want to ask more questions about our patient, talk about how you would treat his depression, or his adjustment disorder, wonder why he repeatedly loses jobs and is there perhaps a personality disorder as well? And no, I don't want an answer, what I want to do is throw out the idea that there probably is no consensus among us about how often patients should be seen. If our patient is seen in a clinic, he may well be started on an antidepressant and told to return in three to four weeks. In a private office, perhaps he'll be told to return in a few days, or maybe not for week or two or three or four. And if there isn't enough disagreement on how often to see patients at the beginning of treatment, what happens if he has a good response to a medication, his symptoms are alleviated, but he still fills the sessions talking-- do we continue to see him daily/weekly/biweekly/monthly if he isn't asking to come less often and if he's paying his bill?